She is in good physical condition and has had no serious illness or operation since her last health examination. During the activity I may be reached at:
Address: _______________________________________________
Phone: _____________________________
If I cannot be reached in case of an emergency, the following person is authorized to act in my behalf:
Name and Address: _____________________________________
________________________________________
Relationship to participant: ______________________
Phone number: ____________________
Physician�s name and number: __________________________
___________________________
Parent�s Signature: ____________________________________
Date: ___________________
My daughter ______ will ______ will not be attending
Adult(s) tubing: _______________________________________
________________________________________